J Community Health DOI 10.1007/s10900-015-0034-0
ORIGINAL PAPER
Age Differences in the Trends of Smoking Among California Adults: Results from the California Health Interview Survey 2001–2012 Yue Pan1 • Weize Wang2 • Ke-Sheng Wang3 • Kevin Moore1,4 • Erin Dunn1,4 Shi Huang1 • Daniel J. Feaster1
•
Ó Springer Science+Business Media New York 2015
Abstract The aim is to study the trends of cigarette smoking from 2001 to 2012 using a California representative sample in the US. Data was taken from the California Health Interview Survey (CHIS) from 2001 to 2012, which is a population-based, biennial, random digit-dial telephone survey of the non-institutionalized population. The CHIS is the largest telephone survey in California and the largest state health survey in the US. 282,931 adults (n = 184,454 with age 18–60 and n = 98,477 with age [60) were included in the analysis. Data were weighted to be representative and adjusted for potential covariance and nonresponse biases. During 2001–2012, the prevalence of current smoking decreased from 18.86 to 15.4 % among adults age 18–60 (b = -0.8, p = 0.0041). As for adults age [60, the prevalence of current smoking trend decreased with variations, started from 9.66 % in 2001, slightly increased to 9.74 % in 2003, but then gradually decreased, falling to 8.18 % in 2012. In 2012, there was a 14 % reduction of daily smoking adults age 18–60 (OR
0.84, 95 % CI 0.76–0.93, p = 0.0006) compared to 2001, while no significant reduction of daily smoking was observed for those age [60. The reductions of smoking prevalence for adults younger than 60 are encouraging. However, there is a concern for smoking cessation rates among those older than 60 years of age, particularly for African Americans. Keywords Smoking trend California Health Interview Survey Age difference
Introduction Cigarette smoking is the leading risk factor for morbidity, premature mortality, and preventable death and is a major public health concern in the United States (US) [1–5]. Sufficient evidence suggests that active smoking is associated with lung cancer, coronary heart disease, and
& Yue Pan [email protected]
1
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
Weize Wang [email protected]
2
Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
3
Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
4
Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
Ke-Sheng Wang [email protected] Kevin Moore [email protected] Erin Dunn [email protected] Shi Huang [email protected] Daniel J. Feaster [email protected]
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numerous other chronic diseases [6]. In 2014, the estimated prevalence of current cigarette smoking was 19.5 % for those aged 45–64 and 8.9 % for those over the age of 64 in the US [7]. Although overall smoking prevalence of all adults declined from 20.9 % in 2005 to 18.1 % in 2012 at the national level, variation may exist across different age groups [7]. The size of the elderly population is increasing, and the age structure of the US population will change dramatically in the next 20 years. The portion of the population older than 65 years of age was 13 % in 2010, and this group is estimated to grow to be 19 % of the entire population in 2030 [8]. Despite lower smoking prevalence among older adults compared to younger adults, older daily smokers were significantly less likely to have made a smoking cessation attempt compared to 18–24 aged daily adult smokers (25.3 vs 53.1 %) [9]. Studies have suggested that current smoking is associated with higher overall risk of deaths among adults older than 65 years of age compared to their same-age counterparts who are lifetime nonsmokers. Increased risk has been found for cardiovascular disease, cancer, and respiratory disease morbidity and mortality among older adults who are current smokers [10]. Risks of smoking are higher among older smokers compared to younger smokers due to their relatively longer smoking history and heavier smoking habits [11]. Older smokers are also less likely to believe that smoking harms their health than younger smokers [11]. There is limited information on the trends in the prevalence of smoking. Particularly, there is no recent, comprehensive assessment of trends in cigarette smoking prevalence for the US elderly population. In this present study, we examined trends in cigarette smoking from 2001 to 2012 using data from the California Health Interview Survey (CHIS), looking for differences by age groups.
from 2001, 2003, 2005, 2007, 2009 and 2011–2012. Weighted analyses were performed to obtain unbiased estimates for the California population. A total of 282,931 adults aged 18 years and over was included in the analysis. Details about the sampling design, data collection methods, data processing procedures, response rate and weighting and variance estimation can be found elsewhere (CHIS 2001, 2003, 2005, 2007, 2009 and 2011–2012) [12–17]. This protocol was approved from Institutional Review Boards from the University of Miami.
Methods
Statistical Analysis
Study Population
We performed all statistical analyses in SAS 9.3 using the SURVEY procedures with final sampling weight and the replicate weights to account for the complex sampling design of the CHIS. Data were merged properly from 2001 to 2011–2012. SURVEYFREQ was used to estimate weighted population proportions for gender, race, education, employment status, insurance, income, and smoking habits. The Rao-Scott Chi square test was used to assess differences in sociodemographic characteristics and smoking habits for different age groups. We then calculated the prevalence of current smokers across gender, age and races for each data collection cycle. Trend analyses were performed using current smoking prevalence as the dependent variable and time as the independent variable.
Data were taken from the CHIS, which is a populationbased, biennial, random digit-dial telephone survey of the non-institutionalized population. The CHIS is the largest telephone survey in California and the largest state health survey in US. The survey is a collaborative study between the University of California, Los Angeles (UCLA) Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute. It collects information for all age groups of health-related behaviors including smoking habits. The sample was weighted to represent the noninstitutionalized population for each sampling stratum and statewide. We combined CHIS data
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Measurements Outcome Variable Smoking habits were assessed and classified as never smoked (has not smoked 100 or more cigarettes in lifetime), current or former smoker for all adults. Those who smoked at least 100 or more cigarettes in their entire lifetime were further classified as smoking every day, some days or not at all. Measurements for smoking habits were consistent from 2001 to 2011–2012. Sociodemographic Gender was self-reported as either male or female. Age was self-reported and stratified by age 18–60 and age [60. Race consisted of five subgroups: White, Latino, African American, Asian and other (including Pacific Islander, American Indian/Alaskan Native, Other single/multiple race). Education was classified as completed high school or less, some college/vocational school, completed college, and greater than college. Employment status and insurance status were dichotomized into either yes or no. Annual income was recoded into three levels: B$30,000, $30,001–$70,000 and [$70,000.
J Community Health Fig. 1 Age 18–60 smoking trend
Fig. 2 Age [60 smoking trend
The coefficients of time and significant level were reported. Multivariable logistic regressions were performed and adjusted for the effects of all other variables using SURVEYLOGISTIC procedure to identify the association of
each factor with each level of smoking habits. All analyses were performed for adults age 18–60 and age [60. We maintained a significance level of 0.05 for all statistical tests.
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J Community Health Table 1 Characteristics for CHIS 2001–2012 via age (N = 282,931)
Age [60
Age 18–60 N
Weighted %
N
Weighted %
184,454
79
98,477
21
77,994
50
38,114
45
106,460
50
60,363
55
Gender Male Female Race White
107,425
45
77,168
66
Latino
35,421
28
5671
11
African American
9644
6
4306
6
Asian
19,259
13
6863
11
Other
12,705
8
4469
5
Education High school or less
63,550
42
35,040
45
Some college/vocational
34,766
18
21,075
17
Complete college
57,782
28
25,447
23
Greater than college
28,356
12
16,915
15
No
47,422
26
73,412
73
Yes
137,032
74
24,894
27
No
29,435
20
3054
4
Yes
155,019
80
95,423
96
B$30,000
55,117
32
41,701
42
$30,001–$70,000
57,959
30
32,232
32
[$70,000
71,378
37
24,544
26
30,680 40,797
17 19
8884 42,217
9 42
112,903
64
47,157
49
30
7078
14
Employment
Insurance
Income
Smoking Current smoke Quite Never
Among who smoke at least 100 in life Everyday Some day
9631
17
1808
4
Not at all
40,847
53
42,260
83
Results Table 1 shows the sociodemographic characteristics of Californian adults by age. Approximately 80 % of adults were less or equal to age 60. In the age 18–60 group, majorities were Whites (45 %), high school or less (42 %), employed (74 %), with insurance (80 %), income [$70,000 per year (37 %) and never smoking (64 %). Among those who smoked at least 100 cigarettes in their lifetime, 30 % were found to smoke every day and 17 % smoke some days. For age[60, differences were found between genders (55 % for female), employment status (27 % for employed), insurance status (96 % for with insurance) and income levels (42 % for B$30,000). For smoking habits, 9 % of the adults
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21,057
were current smokers, and 14 % of those who smoked at least 100 cigarettes in their lifetime smoke every day and 4 % smoke some days. Among adults age 18–60, the prevalence of smoking decreased from 18.86 to 15.4 % from 2001 to 2012 (b = -0.8, p = 0.0041) (Fig. 1). Significantly more men were current smokers than women, and the prevalence of smoking decreased significantly for both gender groups (men from 22.72 to 18.76 %, women from 15.01 to 12.05 %). Most ethnicities had significant reductions in current smoker prevalence except for African American (b = -0.24, p = 0.7242). Other race group reported most the reduction from 24.1 % at 2001 to 15.82 % at 2012 (b = -1.77, p = 0.0088). For adults age [60 (Fig. 2), the prevalence of smoking decreased from 9.66
J Community Health Table 2 Multivariable logistic regression analysis for current smoking (ref = never smoke)
Age [60
Age 18–60 OR
95 % CI
p
OR
95 % CI
p
0.46–0.50
\0.0001
0.38
0.35–0.41
\0.0001
Gender Male
Ref
Female
0.48
Race White
Ref
Latino
0.30
0.28–0.32
\0.0001
0.43
0.36–0.51
– \0.0001
African American
0.77
0.70–0.84
\0.0001
1.65
1.42–1.91
\0.0001
Asian
0.52
0.48–0.57
\0.0001
0.41
0.33–0.52
\0.0001
Other
0.63
0.57–0.69
\0.0001
0.85
0.71–1.00
0.0556
High school or less Some college/vocational
Ref 0.84
0.79–0.89
\0.0001
0.95
– 0.84–1.07
0.3824
Complete college
0.46
0.43–0.48
\0.0001
0.58
0.52–0.65
\0.0001
Greater than college
0.25
0.23–0.28
\0.0001
0.31
0.26–0.37
\0.0001
0.96–1.06
0.7818
1.28
1.16–1.42
0.70–0.78
\0.0001
0.51
0.41–0.64
Education
Employment No
Ref
Yes
1.01
– \0.0001
Insurance No
Ref
Yes
0.74
– \0.0001
Income B$30,000
Ref
$30,001–$70,000
0.84
0.79–0.89
\0.0001
0.78
0.70–0.87
– \0.0001
[$70,000
0.55
0.52–0.59
\0.0001
0.53
0.46–0.61
\0.0001
Year 2001
Ref
2003 2005
0.96 0.90
– 0.91–1.02 0.85–0.95
0.2293 \0.0001
1.03 0.96
0.91–1.17 0.85–1.08
0.5958 0.4882
2007
0.81
0.76–0.87
\0.0001
0.86
0.76–0.97
0.0135
2009
0.74
0.68–0.81
\0.0001
0.95
0.81–1.10
0.4629
2011–2012
0.79
0.74–0.85
\0.0001
0.87
0.76–1.00
0.0554
to 8.18 % from 2001 to 2012 (b = -0.3, p = 0.0141). When looking into older subgroups, the prevalence of smoking declined for female adults from 9.14 % in 2001 to 7.66 % in 2012. However, no variation was observed for male adults (b = -0.16, p = 0.4898). The prevalence of smoking was relatively stable among different races from 2001 to 2012. Only Whites showed a continuous reduction from 9.86 % in 2001 to 7.96 % in 2012 (b = -0.38, p = 0.0004). Asians had the lowest prevalence but a nonsignificant increasing trend from 5.2 % in 2001 to 7.18 % in 2012 (b = 0.34, p = 0.2314). Older African Americans remained as the group with the highest prevalence of current smoking compared with other racial/ethnic groups. Multivariable adjusted logistic regressions were used to examine the association between smoking and socio-demographics in each survey cycle by age (Table 2). Both
age groups showed lower smoking rates among females compared to males. As for race, African American had significantly fewer smokers (OR 0.77, p \ 0.0001) than Whites for adults younger than 60 years of age. However, African-Americans had significantly more smokers than Whites among adults older than 60 years of age (OR 1.65, p \ 0.0001). Education level and insurance status were negatively associated with smoking for both age groups. Employed older adults were more likely to be current smokers compared to unemployed older adults (OR 1.28, p \ 0.0001). In addition, younger females age 18–60 were less likely to be daily smokers than younger males, while older females were more likely to be daily smokers than older males (OR 1.18, p = 0.0003). African Americans and Asians were more likely to be daily smokers than Whites
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across both age groups. Employed older adults were more likely to be daily smokers than non-employed older adults (OR 1.42, p \ 0.0001), while the association was reversed for younger adults (OR 0.86, p \ 0.0001). Consistent reductions of daily smokers were found for younger adults. Although there was an 11 % reduction for older daily smokers in 2012 compared to 2001, there was no substantial change over time for older daily smokers. There were increases in prevalence with variations for the some days smoking category for both younger and older adults over time. Education level, insurance status and income were negatively associated with daily smoking and some days smoking for both age groups.
Discussion In this study, we examined trends of smoking and demonstrated age-specific patterns of smoking trends in the last decade among Californian adults. Further analysis revealed gender and racial disparities in smoking trends. In summary, we observed consistent reductions in current smoking and daily smoking for younger adults. However, the prevalence of current smoking among the elderly showed a decrease with variations. The prevalence of current smoking in adults [60 years of age was 9.66 % in 2001 slightly increased to 9.74 % in 2003, but then gradually decreased to 8.18 % in 2012. The overall prevalence of smoking for adults age[60 was 8.94 % in our study, which was similar to the smoking statistics from adults in United States [7]. The decreasing trend of current smoking in older adults may be attributed to quitting, antismoking programs, and effects of selective mortality in older smokers. Filion et al. [18] also examined cigarette smoking trends in a populationbased sample of Minnesotans aged 75–84 in the Minnesota heart survey and found the overall prevalence of current cigarette smoking was \8 % and did not change substantially over time. Although we found a decreasing trend of current smoking among the elderly in California, the absolute numbers of elderly smokers may still be increasing since the ageing population is growing rapidly [18]. We found that younger males were more likely to be current smokers, daily smokers, and some days smokers than younger females. Similarly, older males were also more likely to be current smokers compared to older females. However, for those who smoke at least 100 cigarettes in lifetime, older females were more likely to be daily smokers than older males. Older African Americans have the highest prevalence of smoking, and there was no clear reduction in smoking trends in our analysis. In fact, among all race groups for older adults, only older Whites showed a consistent reduction in current smoking. Older African Americans were 65 % more likely to be current
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smokers than older Whites, while the current smoking prevalence for younger African Americans was 23 % less compared to younger Whites. In addition, African Americans and Asians were more likely to be daily smokers than Whites regardless of age. Similar to our findings, one recent study showed that smoking contributed to BlackWhite mortality in the US [19]. The study found that smoking has contributed to the black-white life expectancy gap at age 50 for males but not for females. Smokingattributable mortality at age [50 is greater for black males than for white males and helps address the 20 % increase in relative risk for black all-cause mortality [19]. Although for younger adults, employment was to be a protective factor for daily smoking. For older adults, employment was found to be an important predictor of smoking and positively associated with current cigarette smoking and daily smoking in our study. Education level, insurance, and income were consistently negatively associated with current smoking, daily smoking and some days smoking in our analysis, regardless of age. Studies have extensively demonstrated the benefits of smoking cessation and smoking abstinence among older adults, including lower morbidity and mortality from smoking related cancers and cardiovascular disease and increased physical function and improved life quality [20– 22]. Significant improvement in circulation and pulmonary perfusion were the greatest improvements in the first year of smoking cessation [23, 24]. However, other studies have shown no benefit in reducing morality risks from smoking related disease if there is only a reduction in smoking rather than abstinence from smoking [25]. Connett et al. [26] reported that middle-aged smokers and former smokers with mild or moderate chronic obstructive pulmonary disease breathed easier after quitting, and women demonstrated greater improvement in lung function in response to smoking cessation than men. There are challenges in reducing the smoking rate among older adults. Older smokers are characterized as long time heavy smokers, and they are more likely to suffer from smoking related illnesses. In addition, elderly smokers are less likely to obtain correct information about the benefits of smoking cessation even at an advanced age and the potential benefits of cessation aids like nicotine replacement therapy [27]. Differences in certain biological changes are also likely to occur in older smokers, such as age-related cognitive changes [5] and physiological changes [28]. On the other hand, older adults are offered new opportunities for smoking cessation support, such as behavioral counseling and support groups in senior centers or assisted living facilities [28]. Effective treatment combining counseling and medications for smoking cessation show efficacy and reduced healthcare costs [29–31]. However, smoking cessation in the elderly was associated
J Community Health
with different subject characteristics compared to characteristics associated with successful cessation in younger population, suggesting that older smokers may have unique reasons for quitting smoking [32]. The strengths of our study include its large sample size, the population-based random digit-dial telephone survey, multiple data collection cycles from 2001 to 2012, good quality control by well-trained staff using five languages to capture the rich diversity of the population, and weighted data to be representative of the population. Besides examining current smoking status, we also conducted additional analysis for daily smokers and some days smokers. Several limitations should be noted. We used a cross-sectional study design that is subjected to selection bias and has potential for ecologic fallacy and a lack of temporality. In addition, the study findings are limited by the low response rate of CHIS and could only represent to California residents. However, CHIS respondents were matched with the demographic profile of California residents based on 2008 US Census, and the CHIS rate is comparable to the response rates of other telephone surveys in California. In summary, we described the patterns of smoking trends from the CHIS from 2001 to 2012 stratified by adult age. The reductions in smoking among adults younger than 60 years of age are encouraging. The trend of smoking in the elderly population is decreasing with variations. However, due to the growing elderly population, absolute numbers of elderly smokers may be increasing. This is a public health concern that should promote interest in improving smoking cessation treatments and programs for the elderly. Future study is necessary to assess potential motives and benefits associated with smoking cessation for older adults. Acknowledgments The authors would like to thank the support of Data from the 2001, 2003, 2005, 2007, 2009 and 2011–2012 California Health Interview Survey. Conflict of interest
None.
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ORIGINAL PAPER
Age Differences in the Trends of Smoking Among California Adults: Results from the California Health Interview Survey 2001–2012 Yue Pan1 • Weize Wang2 • Ke-Sheng Wang3 • Kevin Moore1,4 • Erin Dunn1,4 Shi Huang1 • Daniel J. Feaster1
•
Ó Springer Science+Business Media New York 2015
Abstract The aim is to study the trends of cigarette smoking from 2001 to 2012 using a California representative sample in the US. Data was taken from the California Health Interview Survey (CHIS) from 2001 to 2012, which is a population-based, biennial, random digit-dial telephone survey of the non-institutionalized population. The CHIS is the largest telephone survey in California and the largest state health survey in the US. 282,931 adults (n = 184,454 with age 18–60 and n = 98,477 with age [60) were included in the analysis. Data were weighted to be representative and adjusted for potential covariance and nonresponse biases. During 2001–2012, the prevalence of current smoking decreased from 18.86 to 15.4 % among adults age 18–60 (b = -0.8, p = 0.0041). As for adults age [60, the prevalence of current smoking trend decreased with variations, started from 9.66 % in 2001, slightly increased to 9.74 % in 2003, but then gradually decreased, falling to 8.18 % in 2012. In 2012, there was a 14 % reduction of daily smoking adults age 18–60 (OR
0.84, 95 % CI 0.76–0.93, p = 0.0006) compared to 2001, while no significant reduction of daily smoking was observed for those age [60. The reductions of smoking prevalence for adults younger than 60 are encouraging. However, there is a concern for smoking cessation rates among those older than 60 years of age, particularly for African Americans. Keywords Smoking trend California Health Interview Survey Age difference
Introduction Cigarette smoking is the leading risk factor for morbidity, premature mortality, and preventable death and is a major public health concern in the United States (US) [1–5]. Sufficient evidence suggests that active smoking is associated with lung cancer, coronary heart disease, and
& Yue Pan [email protected]
1
Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
Weize Wang [email protected]
2
Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
3
Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
4
Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
Ke-Sheng Wang [email protected] Kevin Moore [email protected] Erin Dunn [email protected] Shi Huang [email protected] Daniel J. Feaster [email protected]
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numerous other chronic diseases [6]. In 2014, the estimated prevalence of current cigarette smoking was 19.5 % for those aged 45–64 and 8.9 % for those over the age of 64 in the US [7]. Although overall smoking prevalence of all adults declined from 20.9 % in 2005 to 18.1 % in 2012 at the national level, variation may exist across different age groups [7]. The size of the elderly population is increasing, and the age structure of the US population will change dramatically in the next 20 years. The portion of the population older than 65 years of age was 13 % in 2010, and this group is estimated to grow to be 19 % of the entire population in 2030 [8]. Despite lower smoking prevalence among older adults compared to younger adults, older daily smokers were significantly less likely to have made a smoking cessation attempt compared to 18–24 aged daily adult smokers (25.3 vs 53.1 %) [9]. Studies have suggested that current smoking is associated with higher overall risk of deaths among adults older than 65 years of age compared to their same-age counterparts who are lifetime nonsmokers. Increased risk has been found for cardiovascular disease, cancer, and respiratory disease morbidity and mortality among older adults who are current smokers [10]. Risks of smoking are higher among older smokers compared to younger smokers due to their relatively longer smoking history and heavier smoking habits [11]. Older smokers are also less likely to believe that smoking harms their health than younger smokers [11]. There is limited information on the trends in the prevalence of smoking. Particularly, there is no recent, comprehensive assessment of trends in cigarette smoking prevalence for the US elderly population. In this present study, we examined trends in cigarette smoking from 2001 to 2012 using data from the California Health Interview Survey (CHIS), looking for differences by age groups.
from 2001, 2003, 2005, 2007, 2009 and 2011–2012. Weighted analyses were performed to obtain unbiased estimates for the California population. A total of 282,931 adults aged 18 years and over was included in the analysis. Details about the sampling design, data collection methods, data processing procedures, response rate and weighting and variance estimation can be found elsewhere (CHIS 2001, 2003, 2005, 2007, 2009 and 2011–2012) [12–17]. This protocol was approved from Institutional Review Boards from the University of Miami.
Methods
Statistical Analysis
Study Population
We performed all statistical analyses in SAS 9.3 using the SURVEY procedures with final sampling weight and the replicate weights to account for the complex sampling design of the CHIS. Data were merged properly from 2001 to 2011–2012. SURVEYFREQ was used to estimate weighted population proportions for gender, race, education, employment status, insurance, income, and smoking habits. The Rao-Scott Chi square test was used to assess differences in sociodemographic characteristics and smoking habits for different age groups. We then calculated the prevalence of current smokers across gender, age and races for each data collection cycle. Trend analyses were performed using current smoking prevalence as the dependent variable and time as the independent variable.
Data were taken from the CHIS, which is a populationbased, biennial, random digit-dial telephone survey of the non-institutionalized population. The CHIS is the largest telephone survey in California and the largest state health survey in US. The survey is a collaborative study between the University of California, Los Angeles (UCLA) Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute. It collects information for all age groups of health-related behaviors including smoking habits. The sample was weighted to represent the noninstitutionalized population for each sampling stratum and statewide. We combined CHIS data
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Measurements Outcome Variable Smoking habits were assessed and classified as never smoked (has not smoked 100 or more cigarettes in lifetime), current or former smoker for all adults. Those who smoked at least 100 or more cigarettes in their entire lifetime were further classified as smoking every day, some days or not at all. Measurements for smoking habits were consistent from 2001 to 2011–2012. Sociodemographic Gender was self-reported as either male or female. Age was self-reported and stratified by age 18–60 and age [60. Race consisted of five subgroups: White, Latino, African American, Asian and other (including Pacific Islander, American Indian/Alaskan Native, Other single/multiple race). Education was classified as completed high school or less, some college/vocational school, completed college, and greater than college. Employment status and insurance status were dichotomized into either yes or no. Annual income was recoded into three levels: B$30,000, $30,001–$70,000 and [$70,000.
J Community Health Fig. 1 Age 18–60 smoking trend
Fig. 2 Age [60 smoking trend
The coefficients of time and significant level were reported. Multivariable logistic regressions were performed and adjusted for the effects of all other variables using SURVEYLOGISTIC procedure to identify the association of
each factor with each level of smoking habits. All analyses were performed for adults age 18–60 and age [60. We maintained a significance level of 0.05 for all statistical tests.
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J Community Health Table 1 Characteristics for CHIS 2001–2012 via age (N = 282,931)
Age [60
Age 18–60 N
Weighted %
N
Weighted %
184,454
79
98,477
21
77,994
50
38,114
45
106,460
50
60,363
55
Gender Male Female Race White
107,425
45
77,168
66
Latino
35,421
28
5671
11
African American
9644
6
4306
6
Asian
19,259
13
6863
11
Other
12,705
8
4469
5
Education High school or less
63,550
42
35,040
45
Some college/vocational
34,766
18
21,075
17
Complete college
57,782
28
25,447
23
Greater than college
28,356
12
16,915
15
No
47,422
26
73,412
73
Yes
137,032
74
24,894
27
No
29,435
20
3054
4
Yes
155,019
80
95,423
96
B$30,000
55,117
32
41,701
42
$30,001–$70,000
57,959
30
32,232
32
[$70,000
71,378
37
24,544
26
30,680 40,797
17 19
8884 42,217
9 42
112,903
64
47,157
49
30
7078
14
Employment
Insurance
Income
Smoking Current smoke Quite Never
Among who smoke at least 100 in life Everyday Some day
9631
17
1808
4
Not at all
40,847
53
42,260
83
Results Table 1 shows the sociodemographic characteristics of Californian adults by age. Approximately 80 % of adults were less or equal to age 60. In the age 18–60 group, majorities were Whites (45 %), high school or less (42 %), employed (74 %), with insurance (80 %), income [$70,000 per year (37 %) and never smoking (64 %). Among those who smoked at least 100 cigarettes in their lifetime, 30 % were found to smoke every day and 17 % smoke some days. For age[60, differences were found between genders (55 % for female), employment status (27 % for employed), insurance status (96 % for with insurance) and income levels (42 % for B$30,000). For smoking habits, 9 % of the adults
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21,057
were current smokers, and 14 % of those who smoked at least 100 cigarettes in their lifetime smoke every day and 4 % smoke some days. Among adults age 18–60, the prevalence of smoking decreased from 18.86 to 15.4 % from 2001 to 2012 (b = -0.8, p = 0.0041) (Fig. 1). Significantly more men were current smokers than women, and the prevalence of smoking decreased significantly for both gender groups (men from 22.72 to 18.76 %, women from 15.01 to 12.05 %). Most ethnicities had significant reductions in current smoker prevalence except for African American (b = -0.24, p = 0.7242). Other race group reported most the reduction from 24.1 % at 2001 to 15.82 % at 2012 (b = -1.77, p = 0.0088). For adults age [60 (Fig. 2), the prevalence of smoking decreased from 9.66
J Community Health Table 2 Multivariable logistic regression analysis for current smoking (ref = never smoke)
Age [60
Age 18–60 OR
95 % CI
p
OR
95 % CI
p
0.46–0.50
\0.0001
0.38
0.35–0.41
\0.0001
Gender Male
Ref
Female
0.48
Race White
Ref
Latino
0.30
0.28–0.32
\0.0001
0.43
0.36–0.51
– \0.0001
African American
0.77
0.70–0.84
\0.0001
1.65
1.42–1.91
\0.0001
Asian
0.52
0.48–0.57
\0.0001
0.41
0.33–0.52
\0.0001
Other
0.63
0.57–0.69
\0.0001
0.85
0.71–1.00
0.0556
High school or less Some college/vocational
Ref 0.84
0.79–0.89
\0.0001
0.95
– 0.84–1.07
0.3824
Complete college
0.46
0.43–0.48
\0.0001
0.58
0.52–0.65
\0.0001
Greater than college
0.25
0.23–0.28
\0.0001
0.31
0.26–0.37
\0.0001
0.96–1.06
0.7818
1.28
1.16–1.42
0.70–0.78
\0.0001
0.51
0.41–0.64
Education
Employment No
Ref
Yes
1.01
– \0.0001
Insurance No
Ref
Yes
0.74
– \0.0001
Income B$30,000
Ref
$30,001–$70,000
0.84
0.79–0.89
\0.0001
0.78
0.70–0.87
– \0.0001
[$70,000
0.55
0.52–0.59
\0.0001
0.53
0.46–0.61
\0.0001
Year 2001
Ref
2003 2005
0.96 0.90
– 0.91–1.02 0.85–0.95
0.2293 \0.0001
1.03 0.96
0.91–1.17 0.85–1.08
0.5958 0.4882
2007
0.81
0.76–0.87
\0.0001
0.86
0.76–0.97
0.0135
2009
0.74
0.68–0.81
\0.0001
0.95
0.81–1.10
0.4629
2011–2012
0.79
0.74–0.85
\0.0001
0.87
0.76–1.00
0.0554
to 8.18 % from 2001 to 2012 (b = -0.3, p = 0.0141). When looking into older subgroups, the prevalence of smoking declined for female adults from 9.14 % in 2001 to 7.66 % in 2012. However, no variation was observed for male adults (b = -0.16, p = 0.4898). The prevalence of smoking was relatively stable among different races from 2001 to 2012. Only Whites showed a continuous reduction from 9.86 % in 2001 to 7.96 % in 2012 (b = -0.38, p = 0.0004). Asians had the lowest prevalence but a nonsignificant increasing trend from 5.2 % in 2001 to 7.18 % in 2012 (b = 0.34, p = 0.2314). Older African Americans remained as the group with the highest prevalence of current smoking compared with other racial/ethnic groups. Multivariable adjusted logistic regressions were used to examine the association between smoking and socio-demographics in each survey cycle by age (Table 2). Both
age groups showed lower smoking rates among females compared to males. As for race, African American had significantly fewer smokers (OR 0.77, p \ 0.0001) than Whites for adults younger than 60 years of age. However, African-Americans had significantly more smokers than Whites among adults older than 60 years of age (OR 1.65, p \ 0.0001). Education level and insurance status were negatively associated with smoking for both age groups. Employed older adults were more likely to be current smokers compared to unemployed older adults (OR 1.28, p \ 0.0001). In addition, younger females age 18–60 were less likely to be daily smokers than younger males, while older females were more likely to be daily smokers than older males (OR 1.18, p = 0.0003). African Americans and Asians were more likely to be daily smokers than Whites
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across both age groups. Employed older adults were more likely to be daily smokers than non-employed older adults (OR 1.42, p \ 0.0001), while the association was reversed for younger adults (OR 0.86, p \ 0.0001). Consistent reductions of daily smokers were found for younger adults. Although there was an 11 % reduction for older daily smokers in 2012 compared to 2001, there was no substantial change over time for older daily smokers. There were increases in prevalence with variations for the some days smoking category for both younger and older adults over time. Education level, insurance status and income were negatively associated with daily smoking and some days smoking for both age groups.
Discussion In this study, we examined trends of smoking and demonstrated age-specific patterns of smoking trends in the last decade among Californian adults. Further analysis revealed gender and racial disparities in smoking trends. In summary, we observed consistent reductions in current smoking and daily smoking for younger adults. However, the prevalence of current smoking among the elderly showed a decrease with variations. The prevalence of current smoking in adults [60 years of age was 9.66 % in 2001 slightly increased to 9.74 % in 2003, but then gradually decreased to 8.18 % in 2012. The overall prevalence of smoking for adults age[60 was 8.94 % in our study, which was similar to the smoking statistics from adults in United States [7]. The decreasing trend of current smoking in older adults may be attributed to quitting, antismoking programs, and effects of selective mortality in older smokers. Filion et al. [18] also examined cigarette smoking trends in a populationbased sample of Minnesotans aged 75–84 in the Minnesota heart survey and found the overall prevalence of current cigarette smoking was \8 % and did not change substantially over time. Although we found a decreasing trend of current smoking among the elderly in California, the absolute numbers of elderly smokers may still be increasing since the ageing population is growing rapidly [18]. We found that younger males were more likely to be current smokers, daily smokers, and some days smokers than younger females. Similarly, older males were also more likely to be current smokers compared to older females. However, for those who smoke at least 100 cigarettes in lifetime, older females were more likely to be daily smokers than older males. Older African Americans have the highest prevalence of smoking, and there was no clear reduction in smoking trends in our analysis. In fact, among all race groups for older adults, only older Whites showed a consistent reduction in current smoking. Older African Americans were 65 % more likely to be current
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smokers than older Whites, while the current smoking prevalence for younger African Americans was 23 % less compared to younger Whites. In addition, African Americans and Asians were more likely to be daily smokers than Whites regardless of age. Similar to our findings, one recent study showed that smoking contributed to BlackWhite mortality in the US [19]. The study found that smoking has contributed to the black-white life expectancy gap at age 50 for males but not for females. Smokingattributable mortality at age [50 is greater for black males than for white males and helps address the 20 % increase in relative risk for black all-cause mortality [19]. Although for younger adults, employment was to be a protective factor for daily smoking. For older adults, employment was found to be an important predictor of smoking and positively associated with current cigarette smoking and daily smoking in our study. Education level, insurance, and income were consistently negatively associated with current smoking, daily smoking and some days smoking in our analysis, regardless of age. Studies have extensively demonstrated the benefits of smoking cessation and smoking abstinence among older adults, including lower morbidity and mortality from smoking related cancers and cardiovascular disease and increased physical function and improved life quality [20– 22]. Significant improvement in circulation and pulmonary perfusion were the greatest improvements in the first year of smoking cessation [23, 24]. However, other studies have shown no benefit in reducing morality risks from smoking related disease if there is only a reduction in smoking rather than abstinence from smoking [25]. Connett et al. [26] reported that middle-aged smokers and former smokers with mild or moderate chronic obstructive pulmonary disease breathed easier after quitting, and women demonstrated greater improvement in lung function in response to smoking cessation than men. There are challenges in reducing the smoking rate among older adults. Older smokers are characterized as long time heavy smokers, and they are more likely to suffer from smoking related illnesses. In addition, elderly smokers are less likely to obtain correct information about the benefits of smoking cessation even at an advanced age and the potential benefits of cessation aids like nicotine replacement therapy [27]. Differences in certain biological changes are also likely to occur in older smokers, such as age-related cognitive changes [5] and physiological changes [28]. On the other hand, older adults are offered new opportunities for smoking cessation support, such as behavioral counseling and support groups in senior centers or assisted living facilities [28]. Effective treatment combining counseling and medications for smoking cessation show efficacy and reduced healthcare costs [29–31]. However, smoking cessation in the elderly was associated
J Community Health
with different subject characteristics compared to characteristics associated with successful cessation in younger population, suggesting that older smokers may have unique reasons for quitting smoking [32]. The strengths of our study include its large sample size, the population-based random digit-dial telephone survey, multiple data collection cycles from 2001 to 2012, good quality control by well-trained staff using five languages to capture the rich diversity of the population, and weighted data to be representative of the population. Besides examining current smoking status, we also conducted additional analysis for daily smokers and some days smokers. Several limitations should be noted. We used a cross-sectional study design that is subjected to selection bias and has potential for ecologic fallacy and a lack of temporality. In addition, the study findings are limited by the low response rate of CHIS and could only represent to California residents. However, CHIS respondents were matched with the demographic profile of California residents based on 2008 US Census, and the CHIS rate is comparable to the response rates of other telephone surveys in California. In summary, we described the patterns of smoking trends from the CHIS from 2001 to 2012 stratified by adult age. The reductions in smoking among adults younger than 60 years of age are encouraging. The trend of smoking in the elderly population is decreasing with variations. However, due to the growing elderly population, absolute numbers of elderly smokers may be increasing. This is a public health concern that should promote interest in improving smoking cessation treatments and programs for the elderly. Future study is necessary to assess potential motives and benefits associated with smoking cessation for older adults. Acknowledgments The authors would like to thank the support of Data from the 2001, 2003, 2005, 2007, 2009 and 2011–2012 California Health Interview Survey. Conflict of interest
None.
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